Healthcare Provider Details

I. General information

NPI: 1952402257
Provider Name (Legal Business Name): JUSTIN C POOL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

IV. Provider business mailing address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2100
  • Fax: 208-233-3146
Mailing address:
  • Phone: 208-233-2100
  • Fax: 208-233-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5124950-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1007
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: